I am a German gastrointestinal surgeon doing research on inflammatory bowel disease in the US. I am here to answer any questions about medicine, surgery, medical research and training, IBD and my experience living in the US including Impeachments,...

how close are we to getting a cure for Ulceritive colitis?

Actually, and this is commonly unknown, there is a cure - and it's surgery!

If the entire colon and rectum are completely removed surgically, UC is de facto cured. It also removes the risk of developing Colon CA. I believe only a small percentage of patients need this treatment and/or are open to it. It is a massive, very meaningful step to take, after all.

If you are asking about a less radical approach, I honestly do not know. I do know that current research in the field is simply incredible, and I would like to hope to see significant progress during my lifetime.

That is not a cure.

Not sure why you are getting downvoted, this is in fact misleading. It’s a bit like curing a broken finger by amputating it, if there was no way to fix it otherwise, but I wouldn’t call that a cure, it’s just removing the body part with the problem and not fixing the body part. Cure implies you will get better, many people I presume would rather live with UC than have their entire colon removed.

I absolutely understand where this sentiment is coming from, and I think this is a bit more of a philosophical question. Technically, it is a cure. It is a procedure that ends the medical condition. Does it come with associated risks, potential QOL limitations? Yes, absolutely. Is it the dream-come-true cure? No, not at all. And I can understand every single patient who opts to not have this procedure done; after all this has massive implications on their lives. That being said, there are a good number of people for whom this option actually turns out to be the best one. Either way, this is a very complicated decision to make and includes a lot of different perspectives before making it. It has been very helpful for some people, and I am hopeful we will find many more ways to alleviate people's struggles.

edit: just making really clear, this is for extreme cases of patients suffering from UC.

That’s exactly right. Of all the amazing things modern medicine can do....”the cure” for UC is cut out your large bowel and rectum, sew your asshole shut and shit in a bag. Fuck that. Sorry not sorry for the language. Signed: A frustrated UC sufferer for 15 years.

I am really sorry to hear about what you have been experiencing. I am here and doing what I am doing to raise awareness about these diseases, and to work on making things better! Put yourself first, and take good care my friend!

Considering the immune system is very active in the gut microbiome how is this compensated with a total removal?

Thankfully there are various other very potent immune tissues and organs all throughout the human body; usually we do not see noticeable differences after this procedure. This would definitely be a great area of further research!

Speaking like a true surgeon. If you don't like it just cut it out. Never mind the consequences.

Haha, true. If I can’t cut it out, I’m not interested. But actually, in all seriousness, we go through great lengths to make sure the rest decision is made for the patient by the patient, and that includes extensive talks about the consequences. This procedure is a massive change to one’s life as they know it, so we do not take this lightly! Again, this is a last resort option for special cases, and people that really can’t go without it.

Like many Americans I've been eating too much fast food/junk food. Aside from carrying 25-35 extra pounds I suspect I have some inflammation in my general gut area, whats the best way to address that? I know I should diet till the weight goes away but are there specific foods to avoid or eat that will help improve gut flora?

This is a great question, and a very common problem! First, I applaud you for thinking about this kind of stuff; that can already be a big hurdle for our patients! Obviously, you would need to get your GI system checked properly, if you wanted confirmation if you have an inflammatory disease. That being said, there is always, always, always value in changing life style, even if you suspect you are suffering form inflammation in the gut (let's say you experience lots of stomach pains, diarrheas, etc.).

This might be a boring answer, but it is very true! One of the things you can address is moderation of your junk food intake. Quitting cold turkey will be incredibly difficult, while cutting down is much more easily achievable. It also provides you with smaller goals, that provide tiny milestones for you to reach - which will encourage you even more! Any pound lost will be helpful, not just for you gut!!

Another thing, and I am sure people are aware, is physical exercise. Now, this doesn't mean you start running 5 miles every day. Take it slow, even just making the decision to be more active will already prove helpful! Replace driving to drop off mail at the mailbox with taking a walk, or walk around the office building while eating lunch. Instead of refilling your water bottle once in the morning, just do a couple of ounces, and go more frequently! Hydration is another big one, of course!

You might realize, a lot of this does not even have anything to do with what you are actually taking in! Does that make sense? There is so much damaging stuff that we do or put into our bodies, junk food is just one of them!

Another great tip: moderate smoking (quit if you can, this will be SO helpful!!), moderate alcohol intake. These are super important, just like paying attention to what you eat.

Now, I suspect you would like to know more about actual diet changes! Alright, so first of all, again, moderation on the Junk food. If you feel the urge to snack, try out veggies or fruits over junk. Rule of thumb, plant based and/or Whole Foods are always better than processed food. Lean meat, over red meats. Go for fish! There are a ton of food products that contain just so much nonsense, and lots and lots of sugar and fatty acids. Now, keep in mind, sugar and fats are NOT unhealthy. They are critical to your survival. At the end of the day, everything you consume is energy. If you have a surplus of energy taken in, it will be stored. It can be as easy as that. That being said, especially in re: to your inflammation question, there are so called "good" fatty acids, that have actually been shown to have an anti-inflammatory effect on your gut and body! Fish would be a great source, or any kind of nuts are also very good for that! Probiotics might also help with your microbiota. There are various ways of substituting microbes to your flora, be it pills, drinks or yoghurts. My suggestions is to try out and see for yourself what you like most, because that will make you most likely stick to doing it regularly!

What’s your opinion on “leaky gut syndrome” and the idea that poor diet causes inflammation and leaking of toxins, etc into our bodies? Does this occur only with mucosa damaging diseases like IBD, or is this as prevalent as hemp-sandal salesman would have me believe?

Oh, very good question and also very important! It is important to highlight the difference between "leaky gut syndrome" as a sole reason for a disorder, or even its own medical condition versus "leaky gut" (increased gut permeability!) as part of what causes gut disease. I personally am wary of the "leaky gut syndrome" and am more interested in a multi-perspective approach when dealing with my patients and their problems.

While there is definitely truth to the idea that increased permeability affects intestinal homeostasis (this is actually part of my research and super cool!!), we also can say with a certain degree of certainty that - at least in many cases - leaky gut is not the sole reason for IBD or IBS or other intestinal problems. The current hypothesis includes other factors that play huge roles in intestinal balance, including microbiome (so whatever microbes you have, and whatever building blocks they retrieve from your foods and throw at you and into your blood stream), as well as epithelial wound healing! You might have a "leaky gut" but great wound healing in your gut, so any damage caused by - say microbial toxins - is only acute and can be fully repaired (read: healed!). Other people might have a defect in permeability AND wound repair, which may increase the chances of gut problems.

Generally, yes, a leaky gut can have "toxins" leak into your tissues or blood stream, but I think it is important to note that this mostly means "harmful" metabolites from foods, usually because of "poor quality food" or dysbalance of microflora.

Thank you so much for the detailed reply. I don't smoke and I don't really drink to excess but I've noticed feeling less flexible for a couple days after drinking. Luckily I drink pretty irregularly. My digestion doesn't seem distressed very much (stomach pains, diarrhea), I was more referencing like fat around the organs/inflammation there.

I try to eat yogurt but if you look in an American grocery's yogurt section like 95% of it is lowfat yogurt with sugar/HFCS added to sweeten it. The one exception is greek yogurt. What should I look for when shopping for yogurt? If I don't need pro-biotic yogurt that is, just a general healthful snack to help maintain a healthy gut biome. Like I just want to buy some fairly plain yogurt and maybe add some fresh fruit to flavor it.

I don't know if you realized how much this hits home; as a German I LOVE yogurt, and basically any kind of Germany yogurt is incredible. That being said - and no offense USA - but US yogurt just isn't super great. My recommendation would actually be greek yogurt. There is a yogurt called "brown cow" that I found to actually enjoy, so maybe that might be worth checking out?

If you have a surplus of energy taken in, it will be stored

Have you seen the study indicating that cocoa powder lowers the caloric absorption of consumed foods amongst rats? https://news.psu.edu/story/654519/2021/04/13/research/dietary-cocoa-improves-health-obese-mice-likely-has-implications

Obviously, simply eating less is less complicated than eating another substance to reduce caloric intake but can you foresee a future where we can hack our bodirs to absorb fewer of consumed calories?

I have seen this study, yes! I didn't read the entire paper, so I can't comment on it directly. I do believe that certain ingredients (known, still unknown) could probably have an impact on how our body *physically* handles absorption of nutrients (energy) and water. Cocoa seems like a great candidate, actually! If I remember the study correctly, the results were seen after intake of a pretty high amount of cocoa powder - but that is not super relevant, as future research could "concentrate" the amount needed, for sure.

Also, yes, absolutely do I think there will be exciting advances in diet research that will - one day, far down the road - lead to us synthetically enhancing / controlling what we want to absorb. Obviously, this has huge ethical implications, and might lead to various, potentially devastating unexpected other effects on our guts or cause even new diseases, but only time and research will tell! Curiosity it what has kept us going, so yes, I think "hacking" our body in some way or another will be possible. Think about this way, in some ways we already hack our bodies! We eat fruits for vitamins, we can take Vitamin D supplements to help with seasonal disorders, we eat high-fibre diets to help with diverticulitis or drop gluten from our diets to alleviate celiac's disease! But yeah, this will be more "space-y" in the future, until, of course it will become the new normal.

What would be your number one recommendation to people to help alleviate or heal IBS? Especially those that have ‘tried everything’ and just deal with the bad luck of having terrible insides.

IBS can be such a debilitating and frustrating disease; I am sorry to hear about what you are going through and am happy for you to try out different things to see what works best for you! My take on IBS is this: unfortunately there is currently no cure, which means focus must be on alleviating symptoms and learning how to best live with a disease like IBS. While it is not perfect, there are a great many options out there to start taking things into your own hand!

Diet changes, including to avoid foods that trigger your symptoms, drink plenty of water, eat high-fiber foods, avoid "gassy" foods. Exercise, get good sleep. Take lots of care of yourself. There are also medications and supplements, and I am sure you are aware of some, if not most of them already.

Personally, I believe that IBS is really an umbrella term for a group of conditions that we simply do not understand / have discovered yet. I like to hypothesize that perhaps the microbiota is critical to IBS-like disease, or perhaps viral infections (either current / or even past infections) that have a drastic impact on the makeup of your intestinal mucosa; maybe even much more and more long-term than what we are currently thinking. With that being said, there are super exciting clinical studies of fecal transplants. And while this might sound a bit weird or funny at first, there is huge potential in that type of treatment. Restoring a healthy, balanced gut flora has been shown to alleviate GI symptoms. To be honest, and this is completely unscientific, in my mind that just makes perfect sense! Gut microbiota is there for a reason! There are hundreds of millions of them. Why? They are helping us processing all the stuff that we decide to put into our system; and the things we put into our systems have changed over thousands of years, and vary on environment, region, external exposure, even how you are being brought up. These little fellas are there to help you break down everything and create metabolites (sort of building blocks) during digestion; if you have a healthy gut flora, those metabolites are harmless. If there is dysfunction and/or dysbalance, it just makes sense to me that of course there are going to be unwanted, unhelpful, perhaps damaging building blocks - these metabolites have incredibly harmful potential, such as being able to recruit an excessive amount of your immune cells that then start damaging your mucosa. Honestly, I believe that many things are associated with the gut microbiome that we do not simply understand yet. There is fascinating research being done on the gut-brain axis with hypotheses suggesting that diseases such as Parkinson's are actually regulated by gut microbes! That is insane to me, but also not really a crazy surprise, right?

Long story short, one thing I have not mentioned yet and I personally believe is critical to good IBD care - psychotherapy. Psychotherapy is not only incredibly important to learn how to cope with the disease, deal with stress, etc. it also helps with working through underlying negative beliefs, anxieties, fears, lack of self-worth etc. Since I do believe in an more and more relevant, emergent gut-brain axis, this seems critical to me!

edit: Sorry, I just noticed, I meant to say IBD/IBS in my last paragraph of course!

To follow up on this, I had a bout of diverticulitis last week. I also had a chronic cough, which I assume is unrelated. I've been taking Amox-Clav for the past 7 days. My gut is back to normal and my chronic cough has completely subsided. Is it possible that I had a mucosal infection of the lungs?

Weird anecdotal question, I know. Just food for thought.

Thanks for asking! It is always fun for me to think about these things. If you have been experiencing a chronic cough, then yes, absolutely is infection "one of the possible causes". Chronic cough, however, may be caused by many other things. How long did you have the cough? What did the mucus look like? Was there mucus? What about other symptoms? What's your job? Where do you live? Medical history? Did you travel recently? Stomach burns? Weight? Diet? Do you smoke? Drink alcohol? Family history? And so on!

Seeing as how your cough went away following an antibiotic course, it at least seems reasonable to think that perhaps it may have been a bacterial infection. Maybe it was just great timing or luck! Either way, I am glad you are doing much better.

Hey thanks for doing an AMA, I'm sure people at r/IBS would love this. Currently on a waiting list to see a gastro myself, pretty severe IBS symptoms for years now. Any new or exciting research being done into understanding more about IBS? It's so difficult working with a gp trying to get additional testing done when they can just say "oh its IBS".

Also standard gross question, just how concerning is an abundance of mucus in the stool?

Cheers

Hey, thanks so much for your question! I am glad to hear you are taking care of yourself. I am so sorry this happens to patients, but to not ever let yourself get discouraged, especially your own health! That is simply the most important thing! And having a chronic disease doesn't automatically mean it is less debilitating, or worth less of medical attention. That is insane to me; if anything chronic disease needs to be treated with as much compassion, effort and exciting treatments as possible!

There is great and super exciting research on IBS, actually, and I will sort of refer you to one of my other comments below (above? haha no idea). One of the most exciting things to me, personally, is fecal transplantation! It has been shown that we can actually restore a balance microbiome in the gut, which is critical to IBS treatment (maybe even one day prevention!!). Even more generally, studies on microbes (including viruses) are incredibly exciting, because the are more and more relevant in all respects of disease and medicine. Neurodegeneration is looking more and more to be highly regulated by the GUT, isn't that insane? IBS is super important, and just as IBD research, I think it is one of the most important areas of research, as the chronic nature of these debilitating, stigmatized disorders is a huge burden for our patients!

In respect to your other question, it really depends on "how much is too much". Usually the gut produces mucus all the time, but usually fairly small amounts, clear and thin. If there is a difference in that, then that can be a sign of many things: changes in diet, infection (even something like a sinus infection!), chronic inflammation in the gut (like Crohn's disease) or even an anal fissure or hemorrhoids. Really anything that can aggravate your intestine. If the mucus has a different color or it seems to you like a lot, then that can always be worth checking out!

It is unhealthy to hold farts in?

Truly the question I have been waiting for (except for maybe what objects we extract from bowels..).

Honestly, I do not believe there is a lot of scientific evidence on it being harmful or not. What I can tell you is that is causes short-term discomfort, including pain, bloating, it even increases the risk of an unwanted, uncontrollable spontaneous fart (and we all know how we feel about that). Other than that, I could imagine that perhaps "chronic holding it in" could lead to increased stress levels, just because of the discomfort you may experience; and the risks of elevated stress levels of fairly commonly known.

So, totally unscientific opinion, holding in farts may be less healthy than letting it rip?

I was told holding farts in could exacerbate inflammation of diverticula or cause a perforation. Would you agree?

I do not know whether there is any evidence for this; I have never heard about this. Purely personally speaking, so this is not medical advice, it is hard to imagine how that would actually have a significant impact, especially on inflammation. Maybe, big maybe, if you already had a tiny perforation and you were going to release a LOT of gas, but you hold it, you end up distending your own bowels and increase the likelihood of the hole getting bigger? This is pure speculation; I am just trying to see how it might be possible, haha

Thanks for doing this! What's one thing the US should learn from German healthcare system, and Germany from US?

This is a great question!

This might not be surprising, but the US could definitely benefit from learning a thing or two about health insurance, and how to make health care as accessible as possible!

Germany would profit if they started taking research more seriously as it usually is the case in the US; also teaching in academia is more highly respected and supported in the hospital setting, which is something that still is undervalued in Germany.

I'm an American living in Germany. I pay $93/month for private health insurance and everything is covered. No co-pays. No deductibles. I just go to the doctor, specialist, whoever, and that's it. And - my doctors here have been more thorough than my US doctors. The US needs universal, comprehensive health insurance for everyone and it is possible.

I am so glad you have been having a good experience with our medical system! Of course there is always room for improvement. Waiting times (in the ER/clinic and for appointments with specialists) for instance need to be addressed!

Do you recommend taking probiotics on a daily basis? If so, how many billions of strains is too much and just a marketing ploy?

So this is a really great question!

Probiotics are really interesting. The general idea is really smart; but the approach is sort of questionable and a bit overhyped. There is no evidence that would suggest a benefit of probiotics on people with a healthy gut. However, probiotics have been found to help patients suffering from various gut diseases. As an example, researchers found that probiotic treatment around an antibiotic treatment helped prevent some of the common side effects associated with AB treatment. Another study found probiotics to be beneficial in a neonatal intestinal disease, and even in IBS probiotics seem to be helpful!

One caveat, the usual doses of microbes in probiotics are Millions - Billions, which is the dose prior to digestion! The order of microbes in a human gut is magnitudes larger, so this is sort of a drop in the bucket. But, if you ask your doctor or dietician, it can definitely be helpful to incorporate this into your diet. I also agree with a comment below; a great source would be natural foods!

How bad does hemorrhoid banding hurt?

Great question! While I have not experience this myself (phew!), I can tell you what patients usually describe. So, the procedure includes the surgeon inserting a band to tie off the hemorrhoid, which will then die due to lack of blood supply. Doctors usually ask their patients how the bands "feel" and if they are too tight. Generally, it is a tolerable experience, and patients might end up experiencing pain 24 - 48 hr. This can mostly be controlled by taking ibuprofen or Tylenol. In the rare case of extreme pain (during procedure), we can inject an reagent to numb the pain, too!

Thank you for the response. Im getting it done soon. I can be a baby about pain so I'm nervous. My brother just had it done recently and was told to drive himself and he had a hard time getting home. Im not exactly excited to have any work done in my colon, to be honest. But it must be done. My colonoscopy revealed 6 polyps, which I have read is a lot for my age (34). With a family history of colon cancer I feel like im in between a rock and a tough spot.

About four years ago, I had hemorrhoidectomy on a massive external hemorrhoid and a stapled hemorrhoidectomy for some even more massive internal hemorrhoids. It was agony. But it sounds like you're doing the band ligation which isn't supposed to be as bad. All I can tell you is changing your diet permanently is way less of a pain in the ass than taking the first pain killer-constipated poop after your asshole is literally cut open and sewn back together.

Sorry to hear about your experience; and that is great advice! No matter what - before a procedure, after a procedure, or even without having to get a procedure - a change in diet can do wonders and alleviate the discomfort!

If the hemorrhoids cause discomfort for you, it is absolutely ok to take of them! I personally would not recommend driving yourself after the procedure, mostly because of the discomfort you might experience (do not drive under any circumstance if you are given a sedative during the procedure!!!). With your family history, it is definitely a good idea to have your colon regularly checked! Your doctor can give you the specifics (depending on number, type and size of your polyps) and based on your family history, how often you would benefit form a colonoscopy. I understand being nervous about it; it is truly daunting to even think about having something done to your intestine! The good news is, most of these procedures, especially colonoscopies, are incredibly standardized and very, very safe!

Andrew Wakefield attempted to find a relationship between measles and crohn's disease which eventually led to him pretty much starting the anti-vax movement through bad research, bad science. How has that affected current research into IBD and the trust in the medical field in general?

Oh man; I don't think there are a lot of things that make me truly angry, but the anti-vax campaign is absolutely ludicrous, and so, so, so damaging to the public health of every single living human. That being said, there is no current evidence suggesting a link between Measles infection (and vaccination!!) and risk of IBD.

Even - let's call it - contentious research as a good effect on research, I would say. Integrity, curiosity and honesty are just the foundation of science - so people *will* go out and either confirm or deny publications.

I would say, baseline, contentious or controversial research isn't damaging in itself. The way we handle information, and how we stopped to think critically, that has been incredibly damaging to science, medicine and progress in general. I believe not only the medically is vastly affected by the current developments of news/information.

The whole point of science is "to always know better". There is always information we do not have. Science collects and consolidates literally *all the available* information on any given topic and expands on it to make sure "we now know better". Sience and research on an institution level certainly have their flaws, don't get me wrong. But distrusting science is one of the biggest mistakes we are currently making.

What made you want to study inflammatory bowel disease specifically in Americans?

What made you want to study inflammatory bowel disease specifically in Americans?

Thanks for the question! That must have been unclear on my end. I am studying IBD in America, but not specifically in Americans! I do basic research on IBD, so I work in a lab with intestinal cells and mice. That being said, studying IBD in specific populations, especially the USA, would be super interesting!

Thanks for the clarification! I was curious if there’s more of a predilection for IBD in American populations, or if it was merely just that you happened to be in America and studying the disease.

What’s your favorite thing about where you’re living now?

Gosh, great question. The food!! But also, because of COVID19, that has been somewhat of an adjusted pleasure. I would say definitely the nature, and also really appreciate how educated and liberal the city is I live in.

What are your thoughts on using cannabis to help treat symptoms or conditions related to IBD and Crohn's disease?

Not OP, but I have ulcerative colitis and had a total colectomy (removal of entire large intestine) and I can say, without a doubt, cannabis helps me. I've gone without to see the difference, and it's 100% better with.

Ok, so this is a great question that will be a bit hard for me to answer because I am working in two different countries with two different laws about cannabis legalization (at least as of now).

Purely from a medical perspective, there is absolutely value in using cannabis and cannbinoid-related drugs to help with all kinds of medical problems. One of which is chronic pain, and I know from experience that UC and MC patients suffer from a great deal of pain. While this is a difficult area and sort of still "very grey" in many countries, I think there is a good amount of evidence starting to show how cannabis might be beneficial medically. Personally, again purely from a medical perspective, I do hope that one day we will be able to legally use everything beneficial we have available to us so that we can help our patients as much as humanly possible.

I have crohns and was told by my consultant that there seems to be a correlation with lack of vitamin D (in addition to lots of other factors) Do you have any insight in this from your research?

Great question, thank you! It has been very clearly demonstrated that Vitamin D deficiency is very common in Crohn's disease patients, which is super interesting in and of itself. The role it plays, and whether it affects immune responsiveness and symptoms, is less clear. Furthermore, Vitamin D is a phenomenal and fun vitamin, which such cool functions, I would be shocked 0% if it was critical to IBD.

I personally do not have more insight into the role of Vitamin D and how it *correlates* with IBD symptoms; there is at least one study I know off that finds lower levels of Vitamin D to be associated with active Crohn's episodes compared to remission (more info here)

Do you think the vagus nerve can cause gut issues?

Yes, absolutely!! The vagus nerve plays a huge, huge role in innervating the GI tract! It provides parasympathetic fibers, which are crucial for digestion and other processes! Really interestingly, vagus dysfunction can lead to gut disease. There is even a procedure where the vagus nerve gets stimulated/modulated, it is super interesting! I always think of "fight or flight" vs "rest and digest". The parasympathetic nervous system ("rest and digest") is absolutely vital!

So what do you think of America? What do you like/ hate?

Thanks for the question, it's a really great one and I think I could talk about this for hours! For the sake of everyone, I will try and keeps this concise. Personally, I love America. I don't know why, but even as a little kid I always dreamed of coming to the US. I remember vividly, when 9/11 happened and I was 10 years old, I grabbed sheets of papers, taped them together and drew a giant US flag in red, white and blue. Why? I have no idea, I was just very sympathetic with the people of this country at the time!

That being said, there are so many controversial topics in America, compared to Germany. I like to bring up this example: In the US, it is a major election issue if Abortion should be legal or not. In the German state that I am from, one election issue was whether we should increase or decrease the hunt of wolves that have come back to live in the forests. I just think that is insane! Despite Germany and the US being very similar and Western countries, there are issues and topics that are of just entirely different dimensions!

2016 - 2020 was rough, no question, and I will be honest with you, it made me re-think a lot of things I thought about the USA. I am still struggling with the divide that is so, so apparent in this nation, it just makes me sad! This country has unbelievable potential, yet in some areas, there is such a baffling lack of progress.

I love how friendly most people are, most people are incredibly welcoming and open. I love how inclusive regions/areas can be. In Germany, social justice issues are much less prominent, so this is a very interesting thing to witness. I am so, so excited to be working with a very diverse team, because it is just such an enriching experience! I love a lot of the food, especially basically everything baked / sweet. Favorite is brownies! I love how there are people in this country, who are incredibly smart, talented, kind, forward-thinking. I hate, that there is almost always a negative to every positive.

Not to mention maybe obvious ones such as gun violence, police brutality and social injustice, I hate how medical insurance works in this country. I just hate it. As a doctor, it is unfathomable to me how people do not have the right to be treated for medical problems. I also hate how education is so expensive in this country. Burdening young, brilliant minds of the future with crippling financial debt is just insane to me. Obviously, hate is a strong word, but you get the idea!

Overall, I still believe very much in the values of this country, and thankfully things have changed greatly since Biden-Harris. I also believe that most things that I do not like about the US are things that will change, eventually, one day.

Can stress alone cause legitimate IBD? I tend to eat very healthy and am religious about my exercise routine and health in general, but I work 12-14 hours a day in a demanding high pressure field and spend 80-100 nights a year bouncing through hotels for work, so even though I keep a great eye on health my stress levels can be through the roof pretty frequently. I'm only able to go to the bathroom once every 3 days, like clockwork, between 6 and 8am, and when I do it is fairly unpleasant. I've had a handful of people tell me that it is just stress, but I have a hard time believing that. Can stress literally bring on a gastrointestinal disorder like IBS?

Great question, and there are already helpful answers below! IBD and IBS are indeed entirely different entities. IBS is thought to be regulated by stress, yes! What you are describing does not automatically make me think of IBS, however, so let me focus on IBD for a sec. I am actually unsure if stress alone can cause IBD; I do not know if anyone knows that currently. What I can tell you is that it can increase the risk of developing it. IBD is a multifactorial disease, so there are many different things that are part of causing it / can cause it. Stress is a generally "unhealthy" factor for your body.

What stress can absolutely do is cause your IBD to flare up; this is similar to many other auto-immune diseases, where it has been shown that stress can cause "flares" (read: increase of symptoms).

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Hi, thank you for sharing your diagnosis with me. While I believe fecal transplants can be a key treatment moving forward, I would caution with one thing: it is not entirely clear what causes IBD! We do believe that disruption of the gut microbiota may play a key role in the disease. Fecal transplants are very new, and only few studies have been published. There is some data that is promising in UC patients, specifically, that shows rough remission rates of 30% (compared to 20 - 40% for medication). For Crohn's disease there are very limited data right now.

I commented on probiotics on another comment; short summary: they can be beneficial if you suffer from an unhealthy gut!

Hi! I have IBD (Crohn's) and have been living with it now for 10yrs. I wondered what your thoughts were about us one day finding a cure or possibly a less extreme way of managing the conditions (perhaps without steroid or biologic treatments)?

Hi and thanks for your question! There is a fairly upvoted comment at the top that talks more about this. There is a cure for ulcerative colitis, but I am afraid it probably would be categorized as fairly extreme - it include removing the entire colon! There is currently no cure for Crohn's disease.

I am absolutely hopeful that treatment options will increase in number and improve in managing it. One exciting potential new option could be fecal transplants! Another area, that in my personal opinion is criminally underrated in IBD therapy, is a focus on improving wound repair! There are some great options and studies going on. Anything microbiota related is incredibly promising and potentially powerful. There are also some other anti-inflammatory molecules being studied that are more natural to humans, such as certain lipids.

I just recently had my gallbladder removed and they told me a few things that I'm not sure I believe:

- it's not hereditary (my entire male lineage on my mums side have all had theirs removed)

- there was little I could do to prevent the accumulation of gall stones (my diet was awful)

- there are no real changes to my life going forward that I should make (surely the bile flowing directly in to my intestines instead of being used up front is an issue)

I'm wondering if you can give me any insight on these. My assumption was that heavily reducing my fat/sugar/processed foods in take would be required going forward. Especially if i'm predisposed to gall stones? My cholesterol levels have generally been low throughout my life so I find it all confusing

Hey, thanks for your questions! Obvisouly I am not your doctor and do not know enough about your case, but generally speaking gall stones can absolutely be hereditary! There are some things that can technically be done to prevent gall stone formation, although that's not super reasonable. One (uncommon!) reason is very quick weight loss, so that could technically be prevented. Other factors are harder to control.

Actually, there technically are no significant effects on your future life. This varies from patient to patient, but experience has demonstrated that most patients to very well without a gall bladder, including eating fatty foods! Perhaps you will experience some pain after a fatty meal, or after alcohol consumption, but nothing compared to colics! If you notice a pattern like it, I absolutely recommend adjusting your diet a bit. Overall, your gall bladder simply stores some of your bile while the liver keeps producing the vast majority of it every day! Actually, once the bladder is removed, we can observe dilated bile ducts, which basically means your body is helping itself.

There are various different kinds of gall stones, including infectious ones, so cholesterol is not necessarily indicative!

How serious are hemorrhoids?

Very good question! First and foremost, this is such a common problem in the population! Also, they are not commonly considered a serious problem. It is hard to quantify, but I can say that complications are pretty rare. These include extreme pain if blood supply is stopped to the hemorrhoid, anemia if they cause bleeding, extreme discomfort if they prolapse (sort of become externalized), technically a blot clot can form in there, which would most likely cause pain. The most serious ones are probably blood loss and potential infection. All of the above are easily treatable and - when noticed - can even be prevented.

Have you seen a relationship between patients with anterior pelvic tilt and IBS? I have- from talking with friends and coworkers who have an obvious tilt and comparing bowel problems. I have had bowel problems my whole life that I didn't know were weird until I lived with other people. My first poo of the day is tiny hard pellets ( like a rabbit), followed about 20 minutes later by a lot of very soft material if not liquid. Every single day I have this hour of going back and forth to the bathroom and then it's fine the rest of the day. It was called IBS, food allergy, maybe ulcers, doctors never really looked into it after the first colonoscopy. I have been "diagnosed" as constipated and was even prescribed laxatives until I could no longer hold my bowels. I described this to doctors for years without knowing what was happening, and then a physical therapist pointed out my hip problem. Since working on my hips, my poops became normal. If I stand without consciously holding my hips at a different angle, I have the morning problem. I believe what happens is my hips crush my lower bowels while I'm standing/active, and this leads to the constipation. Then, when I sit and relax and my back is extended, I suddenly *have to go right away*. This cycle was made harder before I re-learned how to stand and was never helped by meds or diet changes.

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Just information I hope can help others. Doctors where I live tend to just be very well paid drug dealers, and ignore causes of symptoms in order to write prescriptions to mask the symptoms. It was a major relief to me to have an answer for my odd issue.

This is super interesting, thank you for sharing! I do not have any real evidence about this specifically, but I can definitely imagine how pelvic problems may impact bowel movements. To be honest, the area in your pelvis is very tight - it is holding all kinds of stuff, including the rectum and reproductive organs. If bone structures were to aggravated or obstruct the rectum, even if just the outside wall or some nerves lining it, that might lead to either constipation/irregular bowel movement; or the aggravation could trigger an unusual nervous response picked up by the nerves lining the rectum, signaling you *need to go right away* or making your colon stop reabsorbing water, which in turn leads to diarrhea! This is all speculation, but it is fun to think about these things. Thanks again for taking the time to share!

Is gluten intolerance for real? Can it get better with age?

Gluten-sensitive enteropathy, or celiac's disease, is very, very real! I am aware that gluten-free is gaining a lot of traction, especially in this country, and it can be hard to identify people suffering from the disease. Actually, what we currently know is that when you eat Gluten (are are over-sensitive to it), your immune response is activated falsely. Over time, this chronic inflammation causes damage to your intestine, which will lead to symptoms. While there currently is no cure for this disease, a gluten-free diet has been shown to reduce symptoms (sometimes greatly) and actually promote intestinal wound repair and healing (one of my favorite topics). If anything, the sooner the disease is correctly diagnosed, the better the chances of making changes in diet, controlling symptoms and promoting repair!

I have non-celiac gluten intolerance and IBD (ulcerative colitis). Cutting out gluten reduced my symptoms and inflammation by 85-90%!

I tested negative for celiac and found this through doing an elimination diet.

This can indeed happen, which makes it even tougher for us to help every patient! I am so glad to hear you figured this out, and it sounds like you took really good care of yourself and helped yourself massively, great job!!

This is so important to keep in mind: if you as a person struggle with a medical problem, do not be discouraged - by family, friends, work, society, doctors or even a negative test results. None of what we do is a 100% guarantee; at the end of the day, you know your body best. So if you feel like something is not right, it is always worth checking out or trying to take care of it! Again, good for you!!

Why do people underestimate IBS and the impact it has on one’s quality of life?

This is such an important question; and I do not have a great answer.

I have an opinion, however. As with everything in life, anything that is uncertain is automatically terrifying. The unknown scares us; we do not like it as the animal that we are. So we tend to avoid it, consciously or subconsciously. Now, we do not really know a whole lot about IBS; and humans need very clear labels for everything, so we can categorize it, and access information for evaluate a situation and judge. With IBS, that whole thing is much more complicated, because we know less about it. People take it less seriously, maybe because they simply haven't collected enough information to make them believe this is a serious problem. Maybe they are aware of the information, but the general population is still of an opinion that needs time to catch on. It is hard to "evaluate" a human interaction if the other end tells you they are suffering from something that - not only you do not understand - but also science. I think a lot of the times we are subconsciously afraid of "what will happen" or "what that would mean" that we rather ignore it or simply don't pay attention. I have no idea if any of this makes sense.

Either way, awareness needs to be raised for these disorders, which is part of the reason why I decided to do this AMA.

My stomach growls quite loudly and can be constant if I haven't eaten. It sounds sometimes like flatulence, except internally. It's gone up considerably in the last 4 years. Is this normal? I am concerned the change in sound indicates a polyp or growth changing inter-organ fluid dynamics, and therefore sound.

Stomach growls are an interesting thing! The common myth is that it tells you you are hungry, right? It is not entirely clear, I don't think, why it happens. I can tell you, however, that is most commonly is not a bad sign!

The most common reasons / current hypotheses include:

- your intestine is actually moving a lot of air around; when you have an empty stomach your muscles don't have foods/liquids to push around and break down, so they move air instead -- so yes, maybe it means you are hungry

- another reason could be incomplete digestion / malabsorption for various reasons; which leads to increased gas production

- swallowing lots of air, especially when you eat hastily, could be another reason

Oh, I forgot, stomach growling has nothing to do with a polyp or changes in fluid dynamics!

I've had IBS-D for years and fall into the category of "I've tried everything" (low FODMAP diet, cutting out dairy, cutting out gluten, cutting out sugar, etc.) and the only thing thats worked for me is the medication Viberzi. It works like a charm, but I'm really paranoid about long term effects on medications. Do you have any suggestions of things I could try?

Additionally, is there any promise to Fecal Transplant procedures to regulate gut biomes in people with IBS-D?

Hey there, this is a pretty specific question, so apologies (GI surgeon, but not a gastroenterologist). Overall, Viberzi can work great for exactly your condition; this is especially great considering you went through all these other things! Viberzi does have some long term side effects, of course all at very, very low rates of occurrence. The most notable one to me is pancreatitis. Overall, I would recommend following your doctor's suggestion, and if you are worried, reach out to them and/or a second opinion of a specialist. I am sorry I can't be more helpful. I have commented on fecal transplants on other questions, feel free to browse around!

What are the clearest signs through which you can easily differentiate between IBD and IBS, since some symptoms can overlap, or even being the same but with different intensities?

This is a great and really difficult question to answer, as it can be extremely difficult to detect and/or distinguish the two. Overall, I would say both diseases cause:

pain, cramps, constipation, diarrhea

Mostly IBD, but not IBS, causes:

weight loss, joint/eye/skin symptoms, rectal bleeding, fatigue, signs of malnutrition (anemia).

I've heard that part of the reason so many people have developed a gluten intolerance is due to the removal of wheat germ from flour. Is any of this based in research you've come across?

I personally have not heard about this specific information; so it is hard to make solid comment on it. What I can say, however, that I can absolutely believe that we process our foods as a huge (definitely not-yet-fully-understood) impact on our gut AND overall health. So while I do not know about a certain germ specific to flour, I would agree that the way we handle our foods (and continue to evolve harvesting, processing, packaging, storing) has a big effect on us. In a similar fashion, we are starting so evidence how certain immune-challenges during childhood (infection) might be very beneficial for "normal" (read:healthy) immune response. And a lot of "chronic" or "unclassified" diseases (this my hypothesis) will have at least some roots in dysregulated immune response.

Does eating the wrong thing when you are 7 years old change your microbiome and impact your gut and overall health when you are 30 or 60? I have no idea; it seems daunting but also exciting to think about the possibility though.

There has been lots of research into gut microbiome and probiotics lately. Is it possible to restore gut microbes? Ie, if someone has taken antibiotics that knock out a particular strain of gut bacteria, how would you go about restoring a full spectrum of microbes? There are only so many specific strains of bacteria in a given product (yogurt, kefir, kombucha, probiotics). I assume there are many more strains of bacteria that occur naturally in a healthy patient, for example, someone that has had a natural birth and little to no antibiotic treatment.

This is a really great question about a sort of dubious topic. Probiotics have been shown to be beneficial to patients with gut disease. That being said, a lot of the commercial products out there only include few strains, most of which we do not even know if they represent the strains that we see in actual people - Lactobacillus, for instance, is in a lot of products, because manufacturers know how to culture them bid scale. Is that the lactobacillus that we have in our system, which survives stomach acid and digestion until it gets to the colon? Not always clear! There was one meta analysis that found no significant changes of microbiome compositions of healthy patients after probiotic treatment.

That being said, probiotics may be helpful in restoring damaged or lost colonies. Normally, the body can use even small amounts of bacteria to regenerate healthy gut microbiota. A common problem is that usually the niches are already "taken over" by more harmful other strains; this is why some physicians prescribe probiotics around an antibiotic treatment. While killing the bad target microbe, it also kills beneficial microbiota - to avoid harmful germs take over and cause havoc, such as Clostridium difficile (C. diff).

I am not sure about the data available about how well probiotics can restore diversity. We do know that gut microbiome diversity is very important, but the effect of probiotics is unclear to me. I would assume they are not very helpful in that respect, as they usually only include some standard microbes.

Why does lack of sleep worsens digestion?

Great question, and spontaneous answer would definitely relate to "fight and flight" versus "rest and digest" response. Your body is wired in a way that it prioritizes sort of one over the other. If there's a Grizzly bear, your so called sympathetic nervous system will kick: adrenaline shoots into the system, heart rate goes up, blood pressure increases, muscles get tense - everything you need to fight or flight (I suggest flight in this case!).

The Yin to our sympathetic-Yang is the so called parasympathetic nervous system. This one is in charge of all the subconscious actions in the body, mostly related to resting and times after eating! This includes salivation, digestion, but also other things like defacation, sexual arousal etc.

Now, if you lack sleep, you give your body less time to take care of those parasympathetic actions, which includes digestion. Obviously there are other reasons, too. A lack of sleep can lead to increased stress levels, which in turn can impact digestion as well. There are other reasons, too.

Hi there, thanks for doing this. I have IBD, specifically Crohn’s disease. I keep hearing about a MAP vaccine that could really help people like me. How real is this? How far along is this? Is there any merit to this idea?

Again thanks so much for doing this.

This is an interesting topic. There are actually quite a few different vaccine approaches in development / studies. The MAP vaccine is an interesting idea, but clinical studies are severely lacking, so it is hard to say anything about it. I think the idea makes sense, and there is some data supporting the hypothesis, but it is clinically not tested yet as far as I know. There are efforts to move along in animal models, however.

I've long held the belief the two best things about the US are NASA and the National Park System. Do you agree or disagree and why?

Haha, this is an awesome question! Actually, just yesterday I was wearing my NASA t shirt and I follow any NASA related news with great interest. While I used to believe that money could be spent so much better, I do agree that space exploration and security are part of what makes us humans so special; it is also very future oriented, which I always like. Also, holy cow is NASA smart! Parks are wonderful, and nature needs to be taken care of more than ever. Are these things the best things about the US? I don't know; I am thinking Pancakes!

Hey, NASA guy with Crohns here! If you keep working on a cure for Crohns/Colitis, I'll keep working on fun space missions.

On a related note, I wanted to be an astronaut until a few years ago when I read Packing For Mars. They have whole chapters on going to the bathroom in space. That pretty well convinced me that IBD and spaceflight are a bad combo.

This is so awesome, thanks for your reply! Now I know someone who works for NASA, this has already paid off, nice! That's how this works, right? Haha.

Seriously, though, I am happy and excited to keep working on these diseases. In my eyes, especially coming form a GI surgeon, this is some of the most debilitating and disheartening stuff I witness day to day in patients. Also, jeez, I can't even imagine doing space flight, not to mention pairing that with the Everst-climb-of-and-experience that IBD can feel like!

In your professional medical opinion, which politician is most full of shit?

Aren't they all?

I know you can't give medical advice but are there rare GI disorders that don't show up on the standard tests? I'm on month 6 of urgency within 45 mins of eating. My gastro is running out of ideas, and I'm losing hope. I have have ibs-d for 20yrs but this is completely different.

Hey thanks for asking and sharing your diagnosis. Yes, our standard tests usually are designed in a way to be fairly specific for standard diagnoses, if that makes sense? There are definitely rare GI disorders that would not show up on normal tests; that being said, a combination of blood works, ultra sound, scope and perhaps a scan can already tell us a lot! I would probably recommend reconnecting with your doctor or reaching out for a second opinion. Another reason could be, has there been any significant trauma or event in recent memory? IBS is heavily associated with anxiety and stress, so perhaps a life circumstance has changed, or there are other things to consider? That could explain this sort of exacerbated experience right now.

What types of medical issues could be solved (or avoided) by simply drinking more water?

Easy, kidney failure!!!

And to throw in some GI stuff, constipation!

I have an undiagnosed stomach condition. My doctor suspects IBS. I can't have any fruits or vegetables without having pale stool and pain. Does this sound like IBD? I had a colonoscopy and they said I do not have the markers they look for when checking for IBD. My bowel react only to foods, not emotions if that counts for anything.

I am sorry to hear that, this can be a really traumatic experience! Obviously I can't replace your doctor's opinion, so please keep that in mind. IBS is much more common, that people think. I personally suspect that in the future we will find out more and more about how the gut microbiota and viral infections regulated our GI system and may cause problems (this is my theory!). That being said, one thing that jumps to my mind is that perhaps you are fructose intolerant, i.e. your gut has difficulty processing fruit sugars! It might be worth checking out. Pale stools can tell you something about your liver / gall / bile function. This has mostly to do with bile production and how our gut processes fats from the food we eat, so this might be something else worth checking out. This could be anything from mild inflammation in the liver, to benign (not harmful) anomaly of your bile ducts, maybe a cyst or a gall stone blocking bile. It can also be caused by IBD, yes, as chronic inflammation of your gut will make absorption of salts, fats and bile more difficult, which in turn pales your stools. A colonoscopy is usually fairly telling of whether or not you are suffering from IBD; but of course there is never 100% guarantee. IBS can be associated with emotional stress, but does not have to be. It could be IBS, too, but form what you are describing, it does sound to me as if what you are experiencing maybe more related to either an intolerance of certain foods, or chronic inflammation (or other bile/live pathologies).

• How different are medical culture and practices in the US vs Germany?
• How different is the role of nurses in the US vs Germany?
• What's your opinion about American beer?

Hey there and thanks for these great questions!

The medical culture is pretty different, actually! Interestingly, the attitude of doctors and the way doctors interact with patients and vice versa is much more casual in the US! I really like that. People text their doctors, call them by their first name. Unthinkable in many German hospitals!

The role of nurses if pretty similar I would say. One important point: in Germany there are no PAs and no NPs. So often, German nurses do some of the PA/NP work. I think the job is more respected in the US than in Germany, which is great for the US and a shame for Germany.

American beer is absolutely terrible. Just. Terrible.

Thanks for doing this AMA Do you plan to do residency in the united states? And how difficult is it for an international medical graduate to find research work in the US? (For someone with no research experience in his hometown)

Hi there and thanks for the question!

I do not plan on doing my surgical residency in the US. I think it could be fun, but I need to be able to treat every patient with the best care, independent on whether or not they can afford it.

For me personally, both times I got into research in the US (2014 Boston, now as a postdoc) was fairly easy. I would say generally, it is definitely doable and within reach, if you really want to give it a try! My tip, just follow your heart and reach out to a bunch of cool and interesting labs that work on projects you are interested in. More often than not you will be surprised by the response!

Would you say that the study of the gut microbiome is the future of curing gastrointestinal diseases?

Do you think that research will purposefully slow down because there is not much profit to be made in curing the disease?

Great questions. I would definitely refer to some other answers I have already given.

Overall, if studying the gut microbiome will not be the "key", I am at least convinced that it will play a significant role in understanding / revealing / treating and curing many, many diseases, including gut but also other disorders (such as Parkinsons, and probably many auto-immune diseases).

I honestly think that research will excel, if anything. Reagents, infracture, techniques, methods, instruments available to us allow for phenomenal new studies and approaches; it enables studying fields that never could have been studied before. In addition, as history has shown us, as soon as we know something, there is more to be know. Imagine we find out that microbiome is the cause for IBD. Now we need to learn how? Can we interfere? Can we utilize it to treat? Maybe even cure? What does that mean for Parkinsons? For any other auto-immune disease? And most importantly, there will always be new diseases popping up. You do make an important point; unfortunately money dictates greatly what we can and cannot do. It is not just interested of Pharma companies, it is insurance companies, doctors, universities. There is a lot of money in this system; and I wish there was more funding, especially for completely new research or junior researching with brilliant ideas. Lots of grant funding to support your work / independency is based on your preliminary findings, which is really, really tough when you have no money to buy reagents, run a sample, or even have lab space to work in.

Thankfully, university play a significant role in advancing research, so there is at least some guarantee that we will continue studying everything.